Presence of cachexia in the treatment phase of head and neck cancer: a chronic nutritional condition in patients undergoing cancer therapy
Authors: Madhavan Yasasve, Muthupandian Saravanan, Manjusha Muralidharan
Journal: International Journal of Surgery (2023)

Dear Editor, Malnutrition has been defined as a subacute or chronic nutritional condition characterized by a decrease in muscle mass, fat mass and function, including immunological function, brain ability and muscular endurance1. Severe weight loss, a sign of subacute malnutrition, ranges from 20 to 50% in the pre treatment phase for head and neck cancer (HENC)2,3. Malnutrition in HENC patients might have a variety of reasons. A primary cause of malnutrition before therapy is limited food intake, which is caused by mechanical blockage of food or discomfort induced by the tumour. Cachexia, a complicated metabolic state linked with underlying disease and characterized by muscle loss with or without fat mass, may also contribute to malnutrition during this time period4. Malnutrition may develop or worsen during and after treatment as a result of treatment-related oral symptoms such as chewing and swallowing difficulties, discomfort, dry mouth, sticky saliva and taste alterations5. Increased inflammatory activity, such as that caused by radiation-induced mucositis, may potentially be responsible for malnutrition during this phase6. HIGHLIGHTS Malnutrition is described as chronic nutritional disorder indicated by a loss of muscle mass. Cachexia contributes to malnutrition in HENC patients receiving treatment. Swallowing difficulty and oral pain are pre-treatment risk factors for malnutrition in HENC patients. Although malnutrition is widely observed before HENC therapy, statistics on the prevalence of malnutrition following treatment for oropharyngeal cancer are limited. This number increased to 24% when patients got food guidance during and immediately after radiation. Malnutrition was seen in 27 and 6% of HENC patients who received tube feeding during and after radiation, respectively, in the third and sixth months following the commencement of radiotherapy7,8. Other research on malnutrition in HENC patients has focused on nutritional status changes during and after therapy. In a randomized controlled trial on HENC patients treated with radiotherapy, nutritional status worsened 3 months after treatment in all patients who did not receive dietary counselling or dietary supplements, but this frequency was limited to 12% when patients received dietary counselling during radiation therapy. Mean body weight reduced considerably in HENC patients who did not get dietary guidance during and after therapy, to 2.3 kg during treatment and 2.2 kg after treatment9. In all of these investigations, the prevalence of malnutrition decreased in patients who received nutritional intervention within the first 6 months of therapy10. Oral symptoms are widely established risk indicators for malnutrition. Swallowing problems and mouth discomfort were found as key risk factors for malnutrition in HENC patients during the pretreatment phase5. In addition to swallowing difficulties, individuals undergoing treatment for oropharyngeal cancer may experience chewing difficulties as a result of poor dental health or trismus11. Due to radiation-induced mucositis, oral oedema, sensitive oral mucosal surfaces, surgically induced anatomical or temporal changes required to insert a new one to make a prosthesis, edentulous patients are frequently unable to wear their prosthesis for about 3 months after surgery and, in some cases, up to 6 months after radiation or chemotherapy12. Furthermore, trismus can be caused by scar tissue development as a result of surgery or radiation therapy. The link between poor dental health, trismus and malnutrition in individuals with oropharyngeal cancer has never been examined. As a result, it is unclear which oral symptoms are risk factors for malnutrition following therapy for oropharyngeal cancer. Malnutrition is more likely to result from swallowing issues during therapy and, to a lesser extent, after treatment. Researchers should advocate medical examination for swallowing issues and malnutrition in patients after treatment for oropharyngeal cancer to limit the risk of post-treatment malnutrition related to swallowing problems. Thorough investigations should look at whether measures to overcome swallowing issues can minimize or perhaps prevent the occurrence of post-treatment malnutrition. For instance, the nutritionist and speech therapist should jointly evaluate the supposed success of collaborative therapy for treatment-related swallowing issues. Furthermore, while large randomized controlled studies on this topic are currently missing, the role of early tube feeding, for example, through prophylactic gastrostomy insertion, is being investigated. It is now evident that early post-treatment malnutrition is a serious issue in individuals with oropharyngeal cancer. Only swallowing difficulties were strongly related to malnutrition in the interval following oropharyngeal cancer therapy. Ethical approval Not applicable. Sources of funding None. Authors’ contribution Y.M.: investigation, writing – original draft preparation. M.M.: data collection, visualization, writing – original draft preparation. S.M.: conceptualization, writing – reviewing and editing and supervision. Conflicts of interest disclosure The authors declare that they have no financial conflict of interest with regard to the content of this report. Research registration unique identifying number (UIN) None. Guarantor Saravanan Muthupandian.